Provider First Line Business Practice Location Address:
2260 OTAY LAKES RD
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91915-1005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-421-5500
Provider Business Practice Location Address Fax Number:
619-656-4320
Provider Enumeration Date:
12/21/2006